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General Practitioner and Hospital PractitionerBorn in India in 1945.
Overview: Ali Zafar qualified in India in 1967 and came to England in 1970. He began to specialise in diabetes when he worked as a registrar at East Birmingham hospital (now Heartlands) from 1972 to 1975. He became a GP in an inner-city practice in 1975, but continued to work at the hospital diabetic clinic, first as a clinical assistant and then as a hospital practitioner, until he retired in 2006. Both the hospital and his surgery were in areas with a high percentage of Asian people. He first produced an Asian diet sheet in the early 1970s.
Well, I come
and I was born there and brought up there. I did my primary school, college and medical school all in
. I come from a family, basically, of
lawyers. My grandfather was a lawyer, my
father and uncle was a lawyer, but then we were six brothers, and none of us
went into law after that. You know,
there‘s one more doctor... or was a doctor in the family, and I‘m the second
one in that group of... pack of six. After qualifying in 1967, I did some house jobs over there, and then
came over to
in 1970; beginning of 1970. So, I‘ve
been here a number of years.
Well, first of
all we‘ll cover your time in
before moving over to the
. What sort of schooling did you have?
Well, I went to a
local school, and this was what you call an English high school, so… But we… although
the medium of instruction was English, we had to study other languages - local
languages, national languages - and then science subjects. So, you know, it was a fairly average public
And what took
you into medicine?
Not a lot of
thought, initially. It was supposed to
be a sort of stable profession, a good profession, where you served a lot of
people, and it had a lot of opening in terms of job opportunities in
and abroad. So, with that in mind, plus
one of my brother was already doing medicine, was already qualified by that
time, so he encouraged me to go into it, and I decided to follow suit.
And where did
Again, I trained
, in a medical
State, and qualified 1967. So, it was a five years course, plus the
house jobs, et cetera, et cetera.
encountered any diabetes before you began your training?
You mean in the
medical school itself?
No, I meant in
your family, or...
No, we have been
very fortunate. We have got no history
of diabetes in the family, or at least nothing diagnosed. My parents lived to ripe old age, and I‘m not
aware of any diabetes there, either in them or in my sibs.
remember, at all, what your image of diabetes was, if you had any image at all,
before you began training?
Well, my own
impression was that, you know, you were not allowed sweets and sugars, and
things like that. But, more than that,
really, I wasn‘t aware of any complications or long-term impact on lifestyle, etcetera,
etcetera, at that stage.
What do you
remember of first encountering diabetes during your training, and what year
would that have been?
I think, if I
remember correctly, it will be about 1963, ‘64, and we had this patient - this
person - who was admitted into hospital for being started on insulin. It was a big thing to start on insulin in
those days, and my consultant decided to bring him in. I think he was a retired judge, or
something. And that was a big thing, in
those days. Everybody, virtually, from
my class came to see this particular person.
And can you
remember what form the treatment took?
Yes, it was
twice daily injections, in those days, with some monitoring of blood sugar, but
we didn‘t have any sticks to monitor blood. And, basically, I had to send bloods in the lab, and get the results
several days later, to find out what the blood sugar levels were. But, I seem to remember that this man was
pretty unwell. He had neuropathy, he
couldn‘t walk very well, so this may be the reason why my consultant decided to
put him on insulin.
(2) Can you remember how much you were taught
about diabetes during your training?
Difficult one; I
have to go back a lot of years. I don‘t
think it was taught all that well, or in that detail. I‘m just looking back. Maybe, perhaps, we didn‘t have such a high
incidence of diabetes in the community, at that particular time. So, I would say it was just one of these
subjects that was covered, but not particularly emphasised upon. We had much more to do with TB and malaria,
and things which were prevalent in my part of the world, than diabetes, which
was not a particularly fashionable disease, at that time.
And can you
remember the attitude of patients to diabetes?
As I said, my
encounters were not all that many before I came here, and I think most people
were resigned to the fact that they cannot eat certain kind of food, and they
will have to take either tablets or injections. But, it was also, from what I remember, a lot of people didn‘t want to
talk about their diabetes; they wanted to hide the fact. And, in fact, I find that even now, in
particular Asian community in this country, that they don‘t want to talk about
diabetes, and they want to keep it under wraps. So, there wasn‘t a stigma attached to it, from what I understand, but
still people were reluctant to talk about their illness.
I don‘t really
know. You know, people with blood
pressure and heart problems will come up and say "oh, I‘ve got
angina" or "I‘ve got a touch of blood pressure", but nobody came
up and said "I‘ve got diabetes". And, I suppose... I mean, although I said that I don‘t think there was
any stigma attached to it, but I‘m sure people, perhaps, who were suffering
felt that there was a stigma attached to it. And, although they will confess it to the doctors, but they would
certainly not talk it socially.
Why did you
decide to come to
the idea was to come here and get my higher education, and then go back. And that was… you know, the whole idea was to
try and come here for about four to five years, get some experience, get the higher
education, and go back to
. It never happened; I‘m still here, but that‘s
a different story.
(3) You‘d already done two years of house jobs
when you arrived in
in 1970. How were your qualifications
regarded when you came to this country?
Well, those days
were easier, because initially I could apply to become a full member of… not a
full member, but get full registration General Medical Council, at that stage,
even before setting foot in this country. So, I could apply from
and get my full medical registration on the basis of the house jobs and the
degree that I had. So, there wasn‘t a
big problem in that sense.
And had you got
a job to come to when you arrived?
didn‘t. I came with what used to be
called a job voucher scheme. So, I
applied for it in
got the necessary voucher, and I came with my wife and my child, who was about
a year and a half old, at that time. But
then, I had family in
which was, of course, a big support. My
wife‘s brother was already working as a paediatric registrar in
East England, and we actually came to him initially. And then I started looking for a job, but I
didn‘t have the job before coming here.
Tell me about
the first job, then.
all with locums, because initially, obviously, I was very new; I didn‘t know
the system. I recall not having any initiation
to the hospital or to the job. You just
started with a bleep in your hand, and the bleep started to work straight away,
and that was that. So, yes, initially,
it was a few locums around in East England; mainly Colchester,
Ipswich, places like that. And then, from there, on to
when I got my first regular job. So,
difficult days, but a lot of experience in those days.
of diabetes on the locum jobs?
No, I had no
experience of diabetes. In fact, I was
doing a locum mostly in paediatric specialties. So, my first encounter with proper diabetes, in this country, came when
I moved to
Nottingham in 1970, ‘71.
What was your
Well, I was a
SHO in general medicine, and this was a sort of peripheral hospital, which was
really not for acute admission; this was more planned admission. But it had a lot of longer-stay beds. One of the consultant that I worked with was
a diabetologist in the local hospital, so, more or less, I started with diabetes
straight away, as soon as I came in here. And I was responsible to look after a female and a male ward, where, in
those days, my consultant - and other physicians - used to bring in patients,
again for stabilisation on insulin, or those who had complications like
neuropathy or foot ulcers, and things like that. And they needed, sort of, care within the
hospital environment for weeks and weeks and weeks. And I was responsible for them. In addition, I was also doing one clinic a
- so called
which I think
(4) is now
Nottingham. So, I got a lot of experience in that one
year of working there.
Can you remember
what the clinics were like?
terms of number, because I can‘t remember ever finishing before
patient have seen anybody else: a nurse or a dietitian or a podiatrist?
Yes, we had a
facility of dietitian. And, I think, in
the very first job - yes - there was a podiatrist, as well, for foot care, yeah. But that was only in one hospital. Subsequent move to other hospitals, where we
didn‘t have any of that facility. So yes,
that particular hospital was probably advanced for its time, in that sense.
Is this the
The General Hospital,
Nottingham, which is now, I think,
And what role
did you play in determining the patient‘s diet?
Not... you know,
apart from general advice for the patient about their carbohydrate intake and
low fat intake, et cetera, et cetera.We were not the expert, really, to give
them detailed dietary advice; this is why they went to see the dietitian. But, I remember… I mean, I‘ve been involved
in diabetes for so many years, and various kind of diets have come, and various
consultants had their own ways of looking at diet. You know, they often, almost arbitrarily,
decided this person should have a thousand calorie, this person should have
fourteen hundred calorie, this person should have two thousand calories per
day. There were others who were going by
portions, and they would say one
(5) portion of ten gram carbohydrate, and he
should have, you know, six portions or eight portions, or whatever. And then this was up to the dietitian, then,
to try and work out around that, and produce a diet sheet which made sense to
talking about 1970 to ‘71, that there were really kind of two approaches going
on: the calories and the portions?
calories and the portions. But, I mean,
it didn‘t just stop there, because I certainly remember working in Heartlands,
where the consultants were still working on portions - and I‘m talking of
between 1972 to 1975 - and the dietitians were trying to produce a chart
accordingly. This was also a time when
this consultant decided that we haven‘t got enough Asian diets or diet sheets,
and asked me to produce a diet sheet in Asian, in the language that people
could read. And we worked on that, and
we produced something at that particular time.
Can you remember
when that was?
Well, this will
be around 1973, ‘74, when, you know, we were drawing up the size of a spoon:
how much flour one should have for chapattis, and how much rice, et cetera, et
cetera. Because, prior to that, there wasn‘t any
particular Asian diet; were all built around two potatoes, and, you know, other
things. And a lot of Asian patients just
didn‘t understand what to eat and what not to eat.
We‘ll come on to
Heartlands in a moment. But still back
Nottingham, working out these calories, and
you said that the numbers were decided rather arbitrarily.
arbitrarily. I mean, from what… you
know, the basic principle was, was the person… somebody an office worker, a
blue-collared worker or a manual labourer, and, you know, the basis of calorie
ration was dependent on how much physical work they were involved. And if somebody was sedentary, and especially
if they were overweight, I seem to remember they were given thousand calories,
even eight hundred calories a day. I
think it was a totally unrealistic target, even in those days, and I don‘t
think many people actually stuck it out. But that is what was prescribed for them, you know, eight hundred,
thousand calories - just go on a thousand calorie a day, would have been
wonderful. And some patients, I suppose,
did and did try, and some lost some weight as well, but I think it was not a
very realistic way of doing things, but that was the way.
mainly about Type 2 here?
talking mainly of Type 2, yes. The Type
1, of course, the dietitian‘s input was a lot more, because, obviously, with
insulin, they have to have some food around that time, and the blood sugars
were going down. And then to avoid any
(6) glycaemia, et cetera, et cetera, their
portions were also spread out throughout the day. So yes, what I have said so far is mainly
concerning Type 2, yeah.
And then, what
are your memories of the wards, and the people who came onto the wards, in
Well, we had
some very kind sisters and very hardworking nurses. And, I must say, the dedication that I saw in
those days, I do not see it now, but that‘s because society has changed, and we
have all changed, and... But the nurses
and the support sisters were very, very good. I mean, if you wanted four urine examinations a day, it will be done, it
will be charted out, it will be there, they‘ll be weighed weekly; you know,
looked after in many respect. And
whatever the clinicians asked, really was provided by the nursing staff. So yes, a lot of cooperation with nursing
staff and the doctors, and a lot of trust and respect for each other.
historical record, then, how did that commitment show itself, compared with
Well, you know,
times have changed. Perhaps we don‘t
need that much dedication. We don‘t need
to examine the urine four times a day, but, you know, it has been sort of
superseded by blood tests, et cetera, et cetera.In those days, patients
were kept in hospital for long period of time, and now that will be unthinkable,
unless in very, very exceptional circumstances. So, the whole scenario has changed. And, you know, I‘m not saying the nurses are not dedicated - I‘m sure
they are equally dedicated - but the job has changed, and the improvement in
monitoring health has changed as well, so…
What are your
memories of insulin from
Nottingham, 1970 to
Well, from what
I remember, we had supply of soluble insulin, which used to be called, I think,
NPH, and then we had the long-acting insulin - I think we had Isophane, and we
had the PZI, protamine zinc insulin. The
other thing was that it was available in three units: forty, eighties and
hundred units, which is now hundred as a standard. It was available both as pork and bovine
insulin; we didn‘t have any human insulin in those days. So, yes, there was plenty of supply of
insulin, and the choice from which clinicians could try and prescribe for
Any memories of
yes. I mean, I would go back to
Heartland days, and I seem to remember one young pregnant lady who had several
miscarriages. She was a diabetic, and
she was unable to conceive, and she was having first trimester, or even later
miscarriages, and had several of them. And when she became pregnant this time, my consultant brought her
in. And she was literally chained to the
bed pole, kept in hospital for the entire length of her pregnancy. And to our greatest joy and relief, she had a
live birth, and she went home with a baby. And I cannot imagine, now, anybody kept in hospital for six, seven
months, you know, away from their family and home. But that was wonderful in that sense.
(7) Tell me about your next job, after
Well, I worked
in Bulwell area of Nottingham - I don‘t think that hospital exists any more -
and then came to another hospital in
Hagley Road. I think it has got the Area Health Authority
Office now. Now, this job, again, was a
medical job, and I was working as a SHO for medical consultants. Here, it was more acute intake, rather than
the chronic patients that I was seeing at the other place. One of my consultant was an endocrinologist,
so he did have one or two diabetic patients as well, but this was not a
particular hospital for diabetes only. And, as I said, it was mostly dealing with acute medical emergencies,
most of the time.
Should we move
on to your next job, then?
worked there at St
for about a year, I got a job as a registrar in
Hospital, also called
Hospital, in chest medicine. Now, by coincidence, one of my consultant,
who was chest physician, was also diabetologist for
Hospital. So, I got involved in his diabetic clinic,
and also in admitting patients in his unit as registrar, and I was responsible
for looking after them both in clinic and in the ward.
given me two memories from Heartlands. One was of that pregnant woman, and also you said that some people were
still talking about portions when you got there. What other memories do you have of those
years as a registrar, 1972 to 1975?
humorous memories. I mean, I seem to
remember going to the outpatient, and… Now,
East Birmingham Heartland, where it is situated, has got a large ethnic
population around it, and we were seeing, by that time, increasing number of
Asian people coming to the outpatients. I seem to remember one particular gentleman, who looked very grim, very
sad. He came for a follow-up appointment. And I asked… I saw him, and I said, well, you
know, "how are you?", and he said "well, as well as you expect". And he still looked very sad. And I said "well, are you okay? Are you well?". And this man - he was an Asian; he was, I
- said to me that "illness comes from Almighty, and doctors are there to
(8) treat. Now, I‘ve got an illness and what you have done is stop my food. How long am I going to last now?". And he was dead serious about it. I couldn‘t stop, literally not... I smiled,
but literally I was laughing inside. Because, what he meant was that when you are ill, when you are weak, you
eat to keep your strength; you make yourself stronger. And this is a very cultural thing as
well. Now, what you‘re doing is: I‘ve
got an illness from the Almighty, and you‘re telling me I can‘t eat. Well, at that rate, I‘m not going to last
very long, am I? And I really thought
that was hilarious. But another
incident, and it‘s totally opposite to this particular one, was when this guy
came in, and, sort of - again in outpatients - I talked to him. And he looked happy, he wasn‘t complaining,
but I said "well, how are you doing with your diet?". And he said "well, I can‘t eat that
much". I said "what do you
mean?", because I thought, you know, the diabetic diets were really mean,
in terms of quantity, so "what do you mean?" He said, "well look, doctor, you‘ve
given me a diet sheet. Now, I have to
eat my own food, and then I have to eat the diet sheet that you have given me,
and I can‘t eat that much"! And
again, I thought that was wonderful - wonderful, how people take messages from
doctors to their home! But I thought
I‘ll share these two very funny moments in my time.
Was it because
the diet sheet was just English foods, so he had to eat his own Asian food
first, and then the English food on the diet sheet?
You may well be
right. I didn‘t think we had started on
Asian diet, at that time, particularly, but… So, he may well have thought that
this was part of the treatment, and that‘s his normal diet. And he thought, well, that‘s a bit too much
for him to consume.
For those who
can you talk a bit about the area around Heartlands, and the kinds of people
you were seeing?
is basically on the east side of
and it‘s surrounded by several districts, which are now predominantly Asian
areas. Very high number of Pakistanis
and Bangladeshis live in that area. So,
the hospital draws a lot of patients from that particular community. And, with the increasing incidence of
diabetes, obviously, the numbers have grown and grown and grown.
earlier, that you were involved in devising an Asian diet sheet. Can you remember when that was?
I think it would
be around 1973; yes, ‘73, ‘74, perhaps. And the idea came in our head that patients, increasingly, coming to
outpatients were Asians now, whose diet is totally different to the indigenous
diet. And it was not good enough talking
to them in what size potatoes they should have, because we only used to go on
the size of the potato, what sort of size of potato you should have, and
tomatoes, and things like that. Because
all the people… you know, Asian diet does include potatoes and all kind of
other vegetables, but it‘s cooked in a different way, and it‘s eaten in a
different way. And the basic ingredient
- the chapattis and the rice - were not mentioned in the English diet
sheet. So yes, we decided that we must
work on, and we sat down with the dietitian and tried to work out the diet
sheet, which eventually I wrote down in Asian languages and photocopied it, and
gave it to the patients.
Have you any
idea if that was happening all over
or all over the country, at the time?
I couldn‘t be
certain, really, but I don‘t think it was happening in the biggest diabetic
Birmingham, which was based at
Hospital, only couple of miles from
where we were. I didn‘t see any patients
coming from there who had a diet sheet in Asian done for them. So, certainly not in
Birmingham, in my knowledge.
(9) What were the outpatients‘ clinics like when
you were a registrar, from 1972 to ‘75?
They were quite
busy, and they were getting bigger, literally by the month. But we still had only one consultant, one of
myself as registrar, and perhaps one GP clinical assistant, at that time. So, we were still managing all the referrals,
new referrals and the follow-up, between three of us, or, at most, four of us,
at any one time. The bloods were still
not available in 1974, ‘75, so we were still relying on urine test, and the
blood results were coming some days later for us to read and, sort of, get in
touch with the patient if necessary. But
they were quite busy clinics.
And were there
any ancillary services?
Yes, we had the
help of a dietitian. I think chiropody
was coming to… certainly, towards the end of 1974, ‘75, we were getting help
from chiropody. But that was about all,
really, in terms of ancillary service.
Was there any
nurse who was always attached to outpatients, and would have built up a
specialist knowledge, or not?
The nurse I
remember very well was always there, and therefore she had a very good way of
working or running the diabetic clinic. But then she was not, as such, a specialist diabetic nurse. She was, really, working other days for other
clinicians in the same building. But,
just by the virtue of running diabetic clinic for so many years, I think, yes,
she has had that insight into how to handle things.
And can you talk
a bit about what you were seeing, in terms of complications, comparing the
early seventies to now?
we were seeing foot ulcers, we were seeing people coming with kidney problem,
and we were seeing people with retinopathy. And retinopathy screening had become quite common, in that period. It was still in
when I was there, but this was getting much more fashionable. And everybody was trying to play with the
ophthalmoscope, in those days, without dilating the eyes, I must say. But we were still trying to do our best,
under the circumstances. So, yes, we
were seeing complications. We were not
particularly connecting ischaemic heart disease with diabetes, at that
particular time. We were certainly
seeing people coming in with other problems.
Were there many
Some. Thankfully, these were mainly either, you know,
one small toe, a little toe or something like that, so not big
amputations. I think one or two, I
remember, were pretty bad, with vascular disease, and ended up having a
below-knee amputation. But I saw some of
them in later years in general practice, and not necessarily in the diabetic
clinic while I was still working there.
Apart from the
discussion that they had with the doctor, when they were in the room, I don‘t
think there were any special educational sessions, at that particular
time. And I would say, in that sense,
no. The most patients got - and these
were enlightened ones - were given addresses of the British Diabetic
Association, so they could get in touch with them and get some leaflets, but I
don‘t know how many of them actually got in touch with them. But, no, I would say there wasn‘t much
education at that time.
And what are
your memories of the wards in the early seventies?
Well, the ward
that I worked in wasn‘t designed as a diabetes ward. It was a general medical ward with lot of
chest patients; not tuberculosis, because we still used to isolate tuberculosis
patients, in those days, in a different ward. But, you know, they were a mix of everything else, and the
diabetics. We were bringing diabetics
mainly, again, for insulin stabilisation; that seemed to be the commonest
thing. We were admitting, once in a
while, somebody in diabetic ketoacidosis, and then there were some patients who
were coming in because they had foot ulcers and peripheral vascular disease. Probably they needed to come in to have their
treatment, dressings, whatever, and be seen by other disciplines, as well, at
the same time.
And any memories
of individual patients from the early seventies?
Well, I seem to remember
one or two, and certainly one young English woman stands in my mind. When we were talking about diet - and she was
on insulin at that age - she told me, point-blank, that she loves chocolates,
chocolates are part of her life, she is not prepared to give it up - come what
may. And there was not a lot I could
tell her. I mean, we did warn her, but
then that was her answer, in answer to my warning. And it stands out, because she was so
determined to carry on eating whatever she wanted to eat. I felt a bit of a pity, in my own mind, but
there was not a lot I could do.
What are your
memories of pregnant women with diabetes in the early seventies?
It was taken
very seriously by the clinicians, and it was explained to patients, in no
uncertain terms, that we needed a lot of cooperation from them if they were
going to have a live baby. Some of them
already had experience of miscarriages. And because they were young, and they wanted a family, we certainly got
a lot more cooperation from the patient, in terms of diet and other
discipline. I think in the beginning of
my registrar year, I cannot remember having active cooperation with the
obstetricians. But towards the end - and
I‘m talking of ‘74, ‘75 - yes, we started to have clinics in common with the
obstetricians. Before that, the
diabetologists would look after them for so many years, but we‘d inform the
obstetrician that I‘ve got a pregnant diabetic lady, and therefore they will
plan a Caesarean at thirty six weeks, or thirty five weeks; something of that
sort. But joint clinics came fairly late,
in the mid seventies, from what I can remember… from my memory.
And can you
remember how those worked?
Well, it was
certainly a lot more better than, sort of, managing a pregnant diabetic all by
yourself, as a diabetologist, because the other side, you know, obviously, we
were totally ignorant about. And it made
it very much comfortable for patients, and for the clinicians, to have two
sitting in the same clinic: one advising about the insulin, and the other
advising about subsequent course of pregnancy. So, it was certainly a big step forward, I would have thought.
(11) Tell me what you did after you ceased to be
registrar at Heartlands.
I straight away
went into general practice. This was before
the days of vocational training became mandatory. I was offered a partnership, of a sort, in
Birmingham, and I decided
to take that up. So, I moved in general
practice in 1975. I kept my ties with
the diabetic clinic, because my old consultant obviously knew me very well, and
he offered me a position as a clinical assistant, for one session. And I wanted to continue working in diabetes
just the same. So, yes, my contact
remained with the diabetic clinic, in that sense, which was very useful in
general practice, I must say.
What was the
attraction of being a GP in 1975?
Well, it was not
a very attractive job, because it was all sorts of hours, the money wasn‘t very
good. But I think the one thing that was
important from… personally for me is, with a growing family, I wanted one place
to stay and, sort of, settle down and get a house, et cetera, et cetera,
because, until such time, while I was in hospital, we were just moving from one
hospital to another. It was the
stability of the job, really, more than anything else.
You say it was
very useful for you, as a GP, to maintain your link with the hospital. How did that work?
diabetes was one subject which, I think, not every general practitioner felt
comfortable. Well, lot of them didn‘t
feel comfortable in those days, either because they felt they hadn‘t been
trained enough, or they hadn’t enough experience of dealing with
diabetics. So, any diabetics that they
saw in general practice, virtually all of them were referred to hospital and
were followed up in hospital. But,
despite follow-ups, because some of the follow-up appointments could be six
months to one year, patients came to the general practitioner in between. And if you had some working knowledge of
diabetes, it was good to be able to talk in an authoritative way, and be able
to give advice, et cetera, et cetera. And I found that very useful, from that
point of view.
What kind of
area was your surgery in?
again with the high Asian population around. And the surgery, although had a small number of Afro-Caribbeans, and
some Irish, and some other ethnic white Caucasians, it was 60% Asian practice.
Well, we were,
you know, beginning to see more and more, and obviously... But I must say, the general practitioners’
involvement in diabetes was minimal, really. Apart from referring them to hospital, they simply washed their hands of
these people. And I don‘t think patients
expected anything, either, from general practitioner. If they did ask, you know, they were just
told "well, you go to hospital, you ask the questions there". So, it was not impacting in that sense. You know, we are much more involved in
diabetes now with the… in the new contract, the last three years, but before
that, I don‘t think there was such an intense involvement.
And can you talk
about being a clinical assistant for... What was a clinical assistant in the late
Yeah, I mean,
basically my job title changed from being a registrar to a clinical
assistant. My work remained much the
same, except that I was not then involved in any ward work, because I was only
doing outpatient once a week, and that was the only difference. But, in a way, still seeing new patients, old
patients, dealing with whatever came through the door on that particular
day. The difference, really, in terms of
being a registrar was that it involved a lot of in-patient work, and the
clinical assistant was really confined to the outpatient.
You say that
numbers were growing - both in the hospital and in your surgery - and you were
in a mainly an Asian area. Were you
thinking that the incidence among Asians was particularly high, or not, at that
I must say, I
sort of overlooked that; you know, I should have perhaps have spotted it
earlier. But, you know, it didn‘t occur
to me until fairly late that the incidence was very, very high, and a lot of
people who were coming were Asians. I
mean, the impression, initially, was that perhaps we were screening more people,
and doing more... you know, the blood test had come about in the market, at
that time, and people were having their random bloods checked. And that was bringing in the incidence. But, I think, also the fact that the Asian
population who was already here was beginning to get older, and now people were
in that age group where Type 2 diabetes commonly shows up. So, yes; initially I didn‘t, but yes, I think
eventually it occurred to me that the numbers have increased, and they are
increasing very, very fast.
Can you remember
what years "eventually" refers to?
Well, I would
say from 1980 onwards, it seemed pretty obvious. I mean, the diabetic clinics started to
(13) very, very large. From doing one clinic a week with one consultant,
and others had two or three members of other staff, Heartland expanded into
having a full department where there were… I think there are seven or eight
clinics, now, a week. And there are
about six or seven consultants, with a professor at the helms of things. And all the clinics are full. Even now, because, I mean, I was working
there until April last year, and the clinics are still very, very full. So, from one clinic to six or seven clinics,
from one consultant to six or seven consultants, and forgetting, you know, not
talking about the senior registrars and the clinical assistants and the
hospital practitioners. You know, the
number of staff increase actually shows the number of people now attending this
And what were
your reflections on the incidence of diabetes among Asian people?
It was an
explosion. It just felt like an
explosion. Every... And it still feels like an explosion. I almost sense, being a general practitioner,
that if I were to offer global detection test for diabetes to every single
patient of mine, I honestly worry what sort of percentage will actually show up
as diabetes. We‘re offering random
testing, but we‘re not offering it to everybody. But I just wonder, if I did offer, how many
of them will probably not be diabetic per se, but will have impaired glucose
tolerance test. And I think the numbers
will be very, very high. I think there‘s
a lot of hidden diabetes in the Asian community, even today.
Well, I think
it‘s a question of resources, you know. I
mean, it‘s really an epidemiological work. And if the State wishes to take such big epidemiological work, then they
will have to put in a lot of resources. They are already random testing and screening in Mosques and Gurdwaras
and people are coming with letters from these nurses saying, you know, impaired
blood-glucose tolerance test, or high random sugar, et cetera, et cetera. But, I think if we were to offer it to
everybody, a mass screening test, especially within the Asian community, I
really feel that the explosion would be like... you know, it‘s like a time bomb
ticking. The numbers will almost double overnight.
I meant, why the
high incidence among Asian people particularly?
Well, there are
all kinds of theories about diabetes and the Asians. I wonder, as well, just as you do, because as
(14) young person, I don‘t seem to remember seeing
that many diabetics within the community. My family was fortunate enough not to have diabetes as part of the
family history. But I couldn‘t remember
seeing, you know, remember many people on insulin, and things like that, in the
sixties, when I was still in
. I think lifestyle has got to do something
with it, definitely, and the diet. Now,
I don‘t think there is anything wrong with the Asian diet, as long as the
portions are normal. I think what has
happened is that people are eating bigger portions, because they can afford
more food, and they are not interested in taking exercise. So, the incidence of obesity is increasing,
and with obesity is coming Type 2 diabetes. And this is becoming very common. I think it‘s a lot of... lack of education, and I really feel that we
have to, rather than mass screening, we could do mass education on diabetes,
diabetes, diabetes. Because I still, in
general practice, see children who are, you know - not unlike the child who was
on television the other day - fourteen stones. But not to that extent, but, you know, twice their size. This is not healthy. A lot of people who have come from
have come from rural background, where they did a lot of manual work, and they
needed a lot of strength to plough the field and to carry the water, et cetera. So, unless you had the strength, you were not
able to do it. So, if your child is
twice the weight of an average child, you know, he‘s going to be a good
labour... you know, he‘s got a good potential for a good, hard working
labourer. And that culture is still
here, and that‘s why the over-feeding and, you know, sort of looking at these
kids as healthy kids is still there.
And when you say
"we" need to concentrate on education, who‘s the "we"?
Well, as a
community, I think. You know, our
National Health Service is spending a fortune on management of diabetes, and I
think it not just is a part of the, you know, the job of the State, but I think
from the schools, from the community centres, from councils. This message has got to come out loud and
clear, time and time again, because I still feel that there are a lot of people
have just not taken this message. The
other thing I... I mean, this is a digression from diabetes, about, for example,
breast-feeding. I see this as… a very
insignificant proportion of Asian mothers breast-feeding their kids, and I
don‘t understand why. I talk to them, I
ask them, and they have no answer. They
simply sort of shrug their shoulder and walk away, kind of thing. So, you know, the education side is still
there. I think bottle feeding, you could
make your child fatter by bottle feeding, and that‘s probably one of the
reasons why they‘re not breast-feeding.
(15) Can you summarise what you see as the main
changes at Heartlands, from when you started in 1972, up until you finished in
Yeah, I mean, I
would say from 1980 onwards, the actual number of people coming to the clinics
were increasing. Also, I‘m not sure whether
that impacted on it, but
Hospital ceased to
function in the city. They had the
largest diabetic population there. Some
of them got transferred to
and others came to Heartlands, so our numbers increased. But, because of the increasing incidence, the
clinics, per week, had to be increased from one, now to I think about eight a
week. That also meant there were more
physicians with a special interest in diabetes, both as consultants and in the
training grade. And also GPs were
working either as clinical assistant or hospital practitioner. But what I did notice was that we were
getting more and more specialist clinics. I have mentioned the obstetrics and diabetic joint clinic. But we are getting things like diabetes and
renal clinic, for example. Diabetes with
- not necessarily a clinic - but in very close association with peripheral
vascular… the vascular surgeons, to keep an eye on some of these things. The chiropody input was getting more and more
intense, and more and more important and organised. So, you know, basically we were expanding
into more specialised clinics, as well as the normal general clinics for
What about eyes?
Yes, of course. I forgot to mention, there‘s a special clinic
with the eye doctors. Also, I mustn‘t
forget to mention that we have got some very decent facility at Heartland for
retinal photography. Previously, it was ophthalmoscope,
and in the later stages of my practice there, we started to get dilated pupils,
so the nurses were putting in drops before the patients were examined. But now, certainly, with the retinal
photographs, it is getting much more quantified changes that you could follow
up by serial photographs, et cetera, et cetera, so the service has improved enormously.
Can you remember
how the role of nurses changed over that period?
Well, you know,
(16) nurses have come on their own, haven‘t they? They have become diabetic specialist
nurses. I don‘t think anybody‘s now
admitted to hospital for insulin stabilisation, or if they are pregnant, et
cetera- as I have mentioned in my
earlier statement - because we have got such wonderful help from nurses
now. And these ladies will be in touch
with the patient by telephone, by home visits, and they will initiate treatment. Often they will adjust the insulin dosage, et
cetera, and keep patients within the community, which is a much more
satisfactory way of doing things now.
Can you remember
when that specialist nursing started at Heartlands?
I‘m trying to
think, but I think it will be around 1985, ‘86, that the specialist nurses
started to be trained, and then we started getting some input from them. But initially, all used to be just in the
diabetic clinic. Now we‘re getting them
within the community itself.
Can you remember
how you felt about it, initially?
It didn‘t bother
me very much, because we were working as a team. And, as I had input in hospital, I knew most
of them, and most of them were very good friends, and basically we got on very
well. I think, initially, some GPs
were... possibly resented them, because these girls knew more about diabetes
management than most of the average GPs, and they felt a little bit threatened
about it. But, I think, in due course,
everybody has taken to them. I mean, you
know, we‘ve got specialist nurses for a lot of things, and most GPs are very
grateful for the help that they can get from these girls.
mentioned that GPs worked sometimes as either a clinical assistant or a
hospital practitioner. Which, or when,
were you each of those? When did you...
Became one? Yeah, the hospital practitioner grade for
myself, I think, came in 1986, ‘87. I
can‘t exactly remember. But, you know, this
is just a change. I mean, there isn‘t a
great deal of change in the nature of work that I did. Perhaps I got a bit more money, and,
technically, a hospital practitioner becomes an independent practitioner,
independent of the consultant. Whereas,
as a clinical assistant, you are still supposed to be under - not supervision -
but, you know, under consultant most of the time. So, not a lot of change in working pattern,
really. However, I already had very good
relationship with the... my professor at hospital, and that really didn‘t made
any change. In fact, it was him who
pushed me on to become a hospital practitioner, because he felt that, with my
postgraduate degree of MRCP from UK, he felt I - and with the experience that I
had - he felt that it was not very just that I should just continue as a
(17) You‘ve been in general practice since 1975,
and you‘re still in general practice part-time. What have been the key changes during that period?
back between ‘75 and 1985, I think the work of general practitioner remained
quite unchanged, to a large extent. It
was still older style practice: seeing patients, prescribing, and letting them
go home. I think the period after 1985
was certainly different. I think more practice
nurses started to come in, because - except for some teaching practices, and
some sort of very large practices - not many practices had practice
nurses. And how could you do anything,
really, without having a nurse in your practice? So, after mid-‘85 - yes, I think even my
practice employed somebody as a full-time practice nurse. 1990 was the fund-holding year by the Tories,
and that certainly brought in a lot of change, very, very quickly. It certainly empowered general practitioners
in a way they never had before, by holding a fund and by talking to Trust as to
what services they wanted to have. And
there was quite a bit of carrot for them: if they saved money, et cetera, et
cetera, they could keep some of it for their practice development. So, the big changes were, you know, between ‘85
and ‘90, and from ‘90 onwards, I would say.
Were you in
favour of GP fund-holding?
Well, I didn‘t
understand it, initially, because, you know, basically I‘m a doctor by training. And when you start getting funds - and how
many millions you can have, and how do you spend it - it was all very
complex. We had to employ some
professional people, from our management allowance, to have an input. But, yes, I think after the first, you know,
first very difficult twelve months, things started to sink in, about markets,
and how to buy, and how to use your money, et cetera et cetera. But then, sadly, as we were getting
proficient and managing fund-holding, it was sort of all abolished in one go by
the incoming government, and we have now a different system to play with. So, initially not in favour, but I could see
a lot of benefit coming from fund-holding. I think it was a good thing, and should have
probably been left in place.
Did it affect
people with diabetes?
Well, it didn‘t
affect them directly, as such, but it did affect them, because, you know,
(18) practice, for the first time, had money to
employ nurses, for example, or have dietary input. In fact, in the fund-holding days, we used to
get a dietitian to come to our practice once a week, because we could afford
that money for her. And that way, of
course, it was all going towards the patient; it wasn‘t going to benefit us
directly. But, it was making our work
easier, by saying: "you go and see the dietitian today", or "you
see my practice nurse today, you need your serial bloods done", et cetera,
et cetera. So, yeah, it certainly helped
us quite a lot, and the patient.
You say that GPs
used to automatically to refer to hospital. Can you remember when you began to treat people with diabetes more in
your general practice?
speaking, we were doing exactly the same as everybody else was doing. And I would say, probably, not before the
start of the new contract, that in all honesty, I would say, that one has
started looking at referrals very, very carefully, because it impacts on the Quality
Outcome Framework, the QOF points. Plus,
also, every referral has a cost implication. And also the fact that the hospital follow-ups are really, in all
honesty, not very good, because the patients are not seen in less than six
months‘ time, and their blood sugars could be anything but normal. So, I would say, the last three or four years
has seen a major shift from hospital-based clinics to community-based clinic,
and this is going to be more and more. But, I must say, I mean, I know of colleagues who have started… or start
sending patients to diabetic clinic, possibly in the sort of end... towards the
end part of 1990s and beginning of 2000. We didn‘t. But I felt, I suppose,
I had a bit of a vested interest: I was working in the local community hospital. And patients... you know, I was... rather
than seeing them here, I was seeing them there. So, you know, I didn‘t want to see the diabetic clinic contract in the
hospital. Not because of any financial
reasons, but I just felt, initially, that my… you know, I was a bit
apprehensive. Did we have enough
resources in general practice to look after all the diabetics? Did we have the knowledge-base - and I don‘t
mean just necessarily myself, but my other colleagues - to handle
diabetes? But, I think it was not so
much the knowledge, it was the resources, you know. I could see when I went to a diabetic clinic,
I had the dietitian on hand, I had the trained nurses - the so-called
specialist nurses - on hand. If I
prescribed insulin, all I had to do was to say "go and see
so-and-so", and this nurse will take this person through all the pens and
gadgets and everything else. We didn‘t
have that, and we still don‘t have that much. But, I think what has happened is that, because of the incentives of Quality
Outcome Framework or QOF, more and more GPs are dabbling their finger. And because they are dabbling their finger,
they getting the experience and they getting the confidence of managing them in
general practice. Plus, also the fact
that, despite all the resources in hospital, one could say that really the
patients do not necessarily get all that much benefit, because the follow-up
time could be anything between six and twelve months. And a lot can go wrong, and a lot does go
wrong, in that sort of time.
Can you remember
when you started having a specialist diabetic clinic in your surgery?
In the last five
years, we have run our own diabetic clinic. And this carries on, until... to this day. So yes, it‘s a good five years.
(19) Let‘s imagine a patient coming to you with
the symptoms of diabetes now, in 2007. Can
you describe what it would be like for them now, compared with how it was when
you first started in general practice over thirty years ago?
Yes. Patients will be seen within the
practice. And they will probably see the
doctor, initially, but they will be referred back to the practice nurse for all
the bloods, et cetera, et cetera. They
will probably see a dietitian within the practice, or - either in the practice
itself, if it‘s a big enough practice in a health centre - or they‘ll be
referred to a local dietitian within the community clinics. It‘s not necessary that every patient will be
sent to hospital automatically, because there are enough community-based
clinics. And there are some
community-based diabetic specialists as well. So, if a general practitioner wants some urgent advice, he can get on
with this community diabetologist and get some advice, or refer this patient
directly to the community diabetic centre, rather than to hospital. So, the emphasis is transferred from the
hospital to the community-based clinics. The ones that will be left out with the hospitals will be the ones who
have got a lot of complications, on different insulin regime, perhaps, those
who are having multiple injections a day, pregnant ladies, juvenile diabetics, et
cetera, et cetera. But I think the
majority are now being taken care of, and the emphasis is getting patients
discharged from hospital. So, those who
are already in the hospital system, they are being asked… you know, we are
making... requesting the hospitals to actually discharge them back to our care,
so we can continue to see them in the community. So, there‘s a sea-change from that point of
view. Whether it benefits the patient? Well, I think, certainly, it‘s very convenient
for patients, because they know their practice, they know their doctor, and
they can come umpteen numbers of time if they have problem, unlike hospital,
where they have got very rigid six month or twelve months appointment system. And it‘s very difficult to get in as an
extra, unless you really, you know, sort of make a fuss about getting into it
for... and you must have a very good reason to get in there, as well.
Is there any
tension between hospitals and general practice?
I have worked on
both sides. And I think - I don‘t delve
in politics that much - but, yes, there has to be a certain degree of tension,
(20) the hospitals have got their own empires, and
those empires are being threatened. I
mean, I can well see if 60 or 70% of patients are going to be managed in the
community, what justification will be there for, say, having seven or eight
consultants in any Trust, and why there should be that number of clinics. So, instead of the clinics being increased,
the numbers would come down. And I can
see resources being sent into communities. Perhaps some of these consultants will start working in the community,
rather than just working in the hospital. So, yes, there is some tension, and there‘s
bound to be, because the working practices of people in my generation, and even
those who are at least ten years younger than me, is being changed completely. I mean, one of the reasons I retired was that
the changes have been far too many, and I decided to quit. But for people who are ten years younger,
they can‘t quit, you know; they‘ve got to work. So, there‘ll be some tension.
You say you
retired because the changes were too many. Was it that you didn‘t like the changes, or too much admin, or...?
I think the
changes are too many in reorganisation after reorganisation after
reorganisation. Before you get used to
one set of working life, you know, you‘ve got somebody else coming in with some
brilliant ideas. I mentioned GP
fund-holding earlier. I didn‘t know it,
I didn‘t like it, but once I got to know it, once I got to like it, and by the
time I got used to it, it was changed and it became something else. And by the time I got used to second kind of
reorganisation, then came Practice Based Commissioning, you know, so it‘s an
ongoing saga. So, people in my age
group, I suppose, you know, we’re not sort of flexible that much, and it starts
to get a bit too much for day-to-day working. From being a clinician, you start to become more and more and more an administrator
and a financial manager, and all sorts of other things. You‘ve got a lot more worry about other
things, rather than just your practice and your patients, which is how my
generation was not brought up, you know. We were brought up to look after patients, and that was your main
attitude to patients changed at all, during your working life?
I wouldn‘t say
my attitude to patients has changed, but I think the attitude of patients
towards us has changed. They have
certainly been told that they have got more rights to expect, and rightly
so. But the demands have increased,
sometimes for political reasons. Unexpected
level of… you know, they have been asked to sort of
(21) demand things, which really couldn‘t be met
within the existing resources. But that’s
political spin. The lawyers have not
helped by encouraging people to come and complain, and, you know, rather than
having this trust of, the doctors did the best for you, and if something went
wrong, you know, there may be a good explanation for it. People rush up to the lawyers and try and get
money out of it. So, there are a lot of
commercial aspect of things, which is coming to medicine, and which certainly
people of my generation wouldn‘t like. But, my relationship from patient is, in the sense that I think the
loyalties on both sides are getting less and less. We used to have, you know, this thing about
general practitioner being, you know, "you‘re my patient and my practice
and my list size". It‘s all going
by the window, you know. We are not
allowed to have a list size now, you know. If you are registered as a health centre, it‘s the health centre who is
your provider, not a named GP. So, the
loyalties are getting less and less, you know. Every practice has patients who move away from the practice area to
maybe a few miles out of the area, and every practitioner used to have some of
those patients. You know, we all had
wise patients, you know, change your doctor, you know, nearer to you. But then, some, because you... we had known
them for years, they had known them for years, and, you know, there was a relationship. That is getting less and less. General practitioners have got to be very
straight-forward, you know, "sorry, you have moved out of the area. Out!", even though you may be a mile out. But if it came to you wanting something, the
nurses may not want to go in that area, because it‘s not in their catchment
area, or the Trust is not responsible for that area. There are a lot of other logistics have
come. So, I think, you know, the loyalty
that we used to have to each other has certainly dwindled; it‘s not in the same
extent. And certainly the patients
expect much more.
(22) You‘ve reflected on the change in
relationship between patient and doctor. Have you any reflections on diabetes as a disease?
certainly feel that now that this is commonly diagnosed, it has less impact on patients‘
perception. But I certainly remember ten,
fifteen years ago, that this diagnosis had a lot of social impact on the
patient‘s life. Some of them took it in
good grace, and were not particularly bothered about it. Others were completely devastated, and they
thought life has come to an end. But the
other thing is that I still find that a lot of people do not want to talk their
- and I‘m talking mainly of Asian population - they do not like to talk about
their illness with other members of the community. They like to keep it a secret to
themselves. So, yes, it can take some
time before they accept the diagnosis, because, initially, they are in a denial
phase. They‘ll eat whatever they want
to, and they do whatever they want to do, except for some sensible ones, who
would take advice seriously. Others will
simply, sort of, either go completely, you know, be completely devastated, or
the other group will try and ignore it at his own peril. So, it does have impact; it impacts people in
different ways. As I said earlier, some
of them will really feel that this is the end of the world for them. And it‘s only after a few months of
treatment, when the symptoms improve, et cetera, et cetera, that they start
feeling the benefit of it, and they feel that - and by telling them, showing
them, examples of people who are within the community with the disease for the
last twenty, thirty years - that they start getting some, you know, sense that
what they are thinking is probably not the right way of thinking about it.